Education Initiative Improves Antibiotic Prescribing in Respiratory Tract Infections in Rural Primary Care Erin Chiswell, DNP, APRN, FNP-BC
Presentation Information Authors: Erin Chiswell, DNP, APRN, FNP-BC & Debra C. Hampton, PhD, MSN, RN, NEA-BC, FACHE University of Kentucky College of Nursing Learning Objectives Antibiotic Stewardship in Respiratory Tract Infection (RTI) Achieving Successful Practice Integration through: Clinical practice guidelines Effective educational interventions Key components of patient education
Problem Antibiotic Resistance PCP Antibiotic Prescribing RTI Prescribing in PC PC = Primary Care PCP = Primary Care Provider RTI = Respiratory Tract Infection
ROOT CAUSE ANALYSIS CYCLE REINFORCERS PATIENTS Past Treatment Other Prescribers Others on Antibiotics Illness ends on antibiotics Fear Beliefs Quick Fix Expectations Socioeconomic Factors Lack of Knowledge: Viral Illness Self Care Antibiotics: Appropriate Use Potential Harms Resistance Time constraints Patient Demand Fear bad outcomes PROVIDERS Cultural Factors Patient Satisfaction Believe will Obtain Elsewhere Patient Perception of Doing Something Lack Energy to Resist Demand Lack of Knowledge: Effectively Educating Patient Strategies to Reduce Prescribing ANTIBIOTICS IN RTI
Clinical Practice Guidelines (CPG): RTI Management No Antibiotic Prescription Combined Approach Prescribing Strategy Active Education During Visit Delayed Antibiotic Prescription To take or pick up in a few days if symptoms worse
Patient Education Natural History & Duration of Illness Symptomatic Treatment Antibiotics Not Needed Unlikely to help Potential side effects &/or harm Symptoms to Watch / Return for Take Delayed Antibiotic Only If Symptoms Worsen DNP III, VII
Purpose & Objectives Implement Patient & Provider Education Initiative Evaluate Effects on Antibiotic Prescribing in RTI Changes: Antibiotic Prescriptions Immediate Antibiotic Prescriptions
Methods: Setting & Sample Setting: Primary Care Office Rural Kentucky Inclusion Criteria: --Age 2-65 years old --Participating Provider Evaluation --Diagnosis RTI --During Established Time Periods Exclusion Criteria: --High Risk for Complications --Bacterial Diagnosis --Duration of Illness >/= 10 days --Co-morbidities: COPD, asthma, immunosuppression
Intervention Implementation 1 year: March 1, 2014- February 28,2015 Rogers Diffusion of Innovation Framework Provider Education No or Delayed Antibiotic Strategy + Active Education During Visit Patient Education CDC Get Smart Posters Active Education from Provider During Visit with Guideline components Handout Specific for clinic patient population Rural considerations
Procedures Quasiexperimental Pretestposttest Design Retrospective Electronic Medical Record Review Measures Was Antibiotic Prescribed? If yes, Immediate or Delayed? Demographics: Gender Age Group: Child: 2-11 Adolescent: 12-17 Adult: 18-65 Sample Pre-Intervention Group (103) Post- Intervention Group (104)
No Significant Difference Between Groups in Gender (p =.92) or Age (p =.24) Age Breakdown Gender Distribution
Results: Difference in Antibiotics Prescribed Antibiotics Prescribed Pre Post Interpretation Any Type 58 / 103 = 56.3% 30 / 104 = 28.8% Significant (p <.001) Immediate 32 / 103 = 31.1% 14 / 104 = 13.5% Significant (p <.05)
Discussion Findings Significant Total & Immediate Antibiotic Prescriptions = Antibiotic Use in RTI Unexpected Findings Room for Improvement Rural populations Limitations Sustainability Generalizability
Recommendations for Practice Antibiotic Prescribing CAN BE CHANGED Even in challenging settings Education in Patients & Providers IS EFFECTIVE in Decreasing Antibiotic Use New Focus
Conclusions Complex Problem Need for Improvement Study Importance: Antibiotic Stewardship IS ACHIEVABLE
References (7) Altiner, A., Brockmann, S., Sielk, M., Wilm, S., Wegscheider, K., & Abholz, H. H. (2007). Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study. J Antimicrob Chemother, 60(3), 638-644. doi:10.1093/jac/dkm254 (1) Arnold, S. R., & Straus, S. E. (2005). Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev(4), CD003539. doi:10.1002/14651858.cd003539.pub2 (2) Bont, E. G. P. M. d., Alink, M., Falkenberg, F. C. J., Dinant, G.-J., & Cals, J. W. L. (2015). Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review. doi:10.1136/bmjopen-2015-007612 Campo, S., Askelson, N. M., Routsong, T., Graaf, L. J., Losch, M., & Smith, H. (2008). The Green Acres Effect: The Need for a New Colorectal Cancer Screening Campaign Tailored to Rural Audiences. Health Education & Behavior, 35(6), 749-762. doi:10.1177/1090198108320358 Centers for Disease Control and Prevention. (2013). Antibiotic Resistance Threats in the United States, 2013. Centers for Disease Control and Prevention. (2015a). Antibiotic Resistance Solutions Initiative. Retrieved from http://www.cdc.gov/drugresistance/solutions-initiative/ Centers for Disease Control and Prevention. (2015b). Antibiotic/Antimicrobial Resistance CDC. Retrieved from http://www.cdc.gov/drugresistance/about.html Centers for Disease Control and Prevention. (2015c, November 12, 2015). Get Smart About Antibiotics Print Materials for Parents of Young Children CDC. Retrieved from http://www.cdc.gov/getsmart/community/materials-references/print-materials/parents-young-children/index.html Centers for Disease Control and Prevention. (2016). Community antibiotic prescriptions per 1,000 population by state- 2014. Retrieved from http://www.cdc.gov/getsmart/community/images/programs-measurement/usmap-2014.jpg Dempsey, P. P., Businger, A. C., Whaley, L. E., Gagne, J. J., & Linder, J. A. (2014). Primary care clinicians perceptions about antibiotic prescribing for acute bronchitis: a qualitative study. BMC Fam Pract, 15(1), 1. Filipetto, F. A., Modi, D. S., Weiss, L. B., & Ciervo, C. A. (2008). Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance. Patient Prefer Adherence, 2(2), 35-39. Gonzales, R., Steiner, J. F., Lum, A., & Barrett, P. H., Jr. (1999). Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA, 281(16), 1512-1519. Hicks, L. A., Bartoces, M. G., Roberts, R. M., Suda, K. J., Hunkler, R. J., Taylor, T. H., Jr., & Schrag, S. J. (2015). US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis, 60(9), 1308-1316. doi:10.1093/cid/civ076 Hwang, T. J., Gibbs, K. A., Podolsky, S. H., & Linder, J. A.. (2015). Antimicrobial stewardship and public knowledge of antibiotics. Lancet Infectious Diseases, 15(9), 1000-1001. Joint Commission. (2016). Proceedings from the National Summit on Overuse. Retrieved from http://www.jointcommission.org/overuse_summit/ Kenealy, T., & Arroll, B. (2013). Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev, 6, CD000247. doi:10.1002/14651858.cd000247.pub3 Linder, J. A., Singer, D. E., & Stafford, R. S. (2003). Association between antibiotic prescribing and visit duration in adults with upper respiratory tract infections. Clin Ther, 25(9), 2419-2430. Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf, 5(6), 229-241. doi:10.1177/2042098614554919 Lopez-Vazquez, P., Vazquez-Lago, J. M., & Figueiras, A. (2012). Misprescription of antibiotics in primary care: a critical systematic review of its determinants. Journal of Evaluation in Clinical Practice, 18(2), 473-484. doi:10.1111/j.1365-2753.2010.01610.x
References Matthys, J. (2013). Expectations for consultations and antibiotics for respiratory tract infection in primary care: the RTI clinical iceberg--comment. The British journal of general practice : the journal of the Royal College of General Practitioners, 63(614), 462. doi:10.3399/bjgp13x671533 (8) Meeker, D., Knight, T. K., Friedberg, M. W., Linder, J. A., Goldstein, N. J., Fox, C. R.,... Doctor, J. N. (2014). Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. JAMA Intern Med, 174(3), 425-431. doi:10.1001/jamainternmed.2013.14191 Morgan, K., & Hart, A. M. (2009). Families in Rural Settings: Values Regarding Acute Respiratory Infections. Families, Systems, & Health, 27(1), 85-97. doi:10.1037/a0014754 (3) National Guideline Clearinghouse. (2008). Respiratory tract infections - antibiotic prescribing. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. (9/11/2015). National Institute for Health and Clinical Excellence. (2008). Respiratory Tract Infections - Antibiotic Prescribing: Prescribing of Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in Primary Care (Clinical Guideline 69). (4) Ranji, S. R., Steinman, M. A., Shojania, K. G., & Gonzales, R. (2008). Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care, 46(8), 847-862. doi:10.1097/mlr.0b013e318178eabd (9) Regev-Yochay, G., Raz, M., Dagan, R., Roizin, H., Morag, B., Hetman, S.,... Rubinstein, E. (2011). Reduction in antibiotic use following a cluster randomized controlled multifaceted intervention: the Israeli judicious antibiotic prescription study. Clin Infect Dis, 53(1), 33-41. doi:10.1093/cid/cir272 Rogers, E. M. (2010). Diffusion of innovations: Simon and Schuster. (5) Spurling, G. K., Del Mar, C. B., Dooley, L., Foxlee, R., & Farley, R. (2013). Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev, 4, CD004417. doi:10.1002/14651858.cd004417.pub4 The White House. (2015). National action plan for combating antibiotic resistant bacteria. Retrieved from http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html#tabs-835289-2 Tonkin-Crine, S., Yardley, L., & Little, P. (2011). Antibiotic prescribing for acute respiratory tract infections in primary care: a systematic review and meta-ethnography. Journal of Antimicrobial Chemotherapy, dkr279. University of Wisconsin Public Health. (2015). County Health Rankings & Roadmaps. (6) Vodicka, T. A., Thompson, M., Lucas, P., Heneghan, C., Blair, P. S., Buckley, D. I.,... team, T. P. (2013). Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review. Br J Gen Pract, 63(612), e445-454. doi:10.3399/bjgp13x669167 Wong, D. M., Blumberg, D. A., & Lowe, L. G. (2006). Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician, 74(6), 956-966. World Health Organization. (2015). Antimicrobial resistance fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs194/en/ Zhang, X., Yu, P., Yan, J., & Ton, A. M. S. I. (2015). Using diffusion of innovation theory to understand the factors impacting patient acceptance and use of consumer e-health innovations: a case study in a primary care clinic. BMC Health Serv Res, 15, 71. doi:10.1186/s12913-015-0726-2